Organizations did a fantastic job preparing for ICD-10. However, now that the dust has settled, we need to drill down into the data. Specifically, case mix index (CMI). With more than two months’ worth of ICD-10 data, it’s easier to make comparisons and draw logical conclusions. If coding and/or documentation problems exist, they’re likely starting to emerge through your CMI. …

As the ICD-10-CM/PCS deadline approaches, it behooves HIM professionals to remind CDI specialists and physicians about important components of a thoroughly-documented operative note. Such a note supports accurate code assignment for reimbursement, and it also provides an accurate record for continuity of care as well as quality initiatives and legal and research purposes. Most Important CDI Documentation During the next …

Although CDI programs have typically been implemented in the inpatient setting, many organizations are beginning to turn their attention toward outpatient documentation as well. That’s because many of the same documentation deficiencies occur in both settings. Poor outpatient documentation—particularly in the emergency department (ED) record—can also affect inpatient code assignment. As third-party auditors continue to scrutinize both inpatient and outpatient …

Role changes are on the horizon for coding professionals. With the implementation of Computer Assisted Coding (CAC), ICD-10 and Hospital Value-based Purchasing (HVBP), clinical coding will take on different forms and new responsibilities. Traditional coding careers may transition to auditors, data analysts or even clinical documentation improvement / integrity specialists (CDIS). Coders → Auditors Coders morph into auditors when CAC …